Clinical Teaching Tips Resources for Family Physician Teachers

Prepared for the College of Medicine

University of Saskatchewan

by Wayne Weston MD Emeritus Professor of Family Medicine, Schulich School of Medicine & Dentistry,

Western University

Updated March 31 2017

CLINICAL TEACHING TIPS PAGE 2

Table of Contents

Introduction – the Before, During, After

Framework

3

Before: 5

• Find out about the program expectations 5

• Prepare your practice 5

• Orientation – share expectations 6

• Selection & priming 8

• Ongoing needs assessment 9

During:

• Authentic responsibility 10

• Granting responsibility for patient care 11

• Relationship building 15

• Case-based teaching & learning 16

• Case presentation 16

• Discussion & coaching 18

• The One-Minute-Preceptor model 20

• The SNAPPS framework 22

• More about feedback 22

• More about questioning technique 25

After:

• Time for reflection 26

• Other teaching opportunities 26

• Assessment & grading 27

• What to do if your learner is not doing well 27

• Reflection on your teaching 28

• The Triple C curriculum 29

• Other resources 30

• Websites about teaching & learning 31

Appendices: 33

Sir William Osler on rounds

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PLANNING

•Preparation

•Orientation

•Priming

DX PATIENT & LEARNER & TEACHING

•5 microskills

•SNAPPS

•Observe

•Model

REFLECTING

•Discussion

•Reflection

•Reading

•Ongoing needs assessment

•Relationship building

•Climate setting Based on Irby

Clinical Teaching – a Framework

Introduction

he following outline has been prepared as a practical guide for

clinical teachers. It covers the following topics:

▪ Before – how to prepare your practice and orient your learners;

▪ During – how to help students and residents learn from their

interactions with patients;

▪ After – reflecting on your experiences as teachers and helping your

learners to reflect on their learning experiences;

▪ Ongoing activities – climate setting, needs assessment and relationship

building;

▪ Resources – links to many useful websites and articles for more

information on several topics that might interest you.

T

This framework is based on a study of distinguished clinical teachers by David Irby. See Irby DM, Bowen JL: Time-efficient strategies for learning and performance. The Clinical Teacher. 2004;1(1):23-28.

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Fitting students into an already hectic schedule is challenging. Some

research has indicated that the presence of a learner in a practice increases

the workload by about 45 minutes per day.1 But it depends on the office set-

up and the level and skill of the learner. Recent Australian studies show that,

when the students have their own consulting room to see patients on their

own before being joined by their preceptor, there is no increase in workload.

Supervising residents may increase the number of patients the practice can

see each day.2 Preceptors handle the challenge of teaching junior students in

different ways. Some schedule a few less patients on days with students,

e.g., leaving a few blank spots during the day for catch-up time. Others

schedule more spots for walk-in acute problems. They are often more

interesting and appropriate for students. Others just work longer. Sharing the

teaching with colleagues allows you to catch up on days when you don’t

have a student. Throughout this guide I have provided tips to fit into a busy

practice.

Sometimes new clinical teachers wonder if they have anything worthwhile

to teach students and residents – these young people seem to know so much

and may be more up to date than we are. But they often have trouble

applying all that “book learning” to real patients. Because medical school

still focuses on teaching by specialists and learning in a tertiary care setting,

students, and even residents, may feel lost in the uncertainties and

complexities of family practice. They greatly appreciate learning the

practical tips you have acquired from years of working in “the trenches”.

They are often amazed at how much family physicians know and inspired by

the close and longstanding relationships you have with your patients.

It may help to remind yourself what it was like as a clerk or new resident

constantly changing rotations. Just as you got comfortable working up

patients on internal medicine, you were moved to obstetrics or surgery. You

were constantly trying to sort out what was expected – it was like starting a

new job every month. Being greeted in a friendly manner and welcomed into

your practice goes a long way in reducing the anxiety of starting out in

another new setting.

Some of the tips may work well for some of you and not so well for others.

We welcome your suggestions about how to make teaching in your offices

more effective and efficient. Please send your suggestions to me at

wweston@uwo.ca.

1 Vinson DC, Paden C, Devera-Sales A: Impact of medical student teaching on family

physicians’ use of time. The Journal of Family Practice. 1996;42:243-249. 2 Kelly L: Community-based Medical Education: A Teacher’s Handbook. London:

Radcliffe Publishing, 2012.

“A student takes time, there is no doubt about it. But the enthusiasm they bring is infectious. Not only do I teach, but I also learn.” – Rural Family Physician

“Medicine is a calling, a call to service. The patient-centred curriculum reflects this noble tradition of commitment to individual patients, their families and community. The physician's covenant is a promise to be fully present to patients in their time of need - to ‘be there’, even when the physician can offer no cure, to provide relief whenever possible, and always to offer comfort and compassion.” – Curriculum

Philosophy. Schulich School of Medicine and Dentistry.

CLINICAL TEACHING TIPS PAGE 5

BEFORE:

FIND OUT ABOUT THE PROGRAM EXPECTATIONS:

▪ The list of objectives or competencies of the school and of your

department are the guideposts for your teaching and provide a standard

for assessing your students. The College of Family Physicians of Canada

also provides a number of important educational documents:

o CanMEDS-FMU – undergraduate competencies from a

Family Medicine perspective HERE.

o The Shared Canadian Curriculum in Family Medicine

(SHARC-FM). This website provides objectives and

references for 23 key topics for the family medicine

clerkship. Clinical Cards are also provided that summarize

key points for each topic. In addition, virtual cases are

provided for many of the topics that can be used by students

to practice their diagnostic approach HERE.

o Several documents related to Triple C, CanMEDS-FM and

the Evaluation Objectives in Family Medicine for

postgraduate education. Because all family medicine

programs are changing to a competency-based curriculum, it

is important to understand what competencies your resident

must achieve in order to graduate. See the Triple C website

HERE. This website also provides easy access to several

short articles explaining the new Triple C curriculum.

CanMEDS-FM, the list of competencies expected of

graduates of a residency program in family medicine, was last

updated in 2009 and a new version will be available by the

end of 2017. The CFPC Evaluation Objectives flesh out the

specific knowledge and abilities graduating residents need.

o In September 2016, the Association of Faculties of Medicine

of Canada produced the Entrustable Professional Activities

(EPAs) for the Transition from Medical School to Residency.

This is a list of 12 core activities that medical students should

be able to perform upon graduation with only indirect

supervision.

▪ With experience, you will soon know what you can expect of learners at

different levels. If you are not sure if your student measures up, ask the

appropriate Coordinator or Director in your department or school.

It is important for you to know what your Department expects your learners to be able to do as a result of their time with you. The list of objectives or competencies provided by your Department, as well as related documents from the CFPC, are a good guide. The assessment is another important guide to what you should teach. The new EPAs are a nice short guide to what students should be able to do at the end of medical school.

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PREPARE YOUR PRACTICE:

et your office staff know about your involvement in training young

physicians and about the students’ role with your patients so that

they can help prepare patients to see a student or resident and answer

any questions about this process. Also let your patients know –

usually they will be proud to know that you have been selected for this

important role. It may be helpful to post a sign in the waiting room about

your involvement with the medical school. You could even post the name of

your student or resident in the waiting room near the reception area to

remind patients of their name to make it more likely that they will follow-up

with the same resident. You might consider having someone in your office

write an article for the local newspaper about the clinic’s involvement in

teaching. Clerks are given significant responsibility for patient care and are

not “fifth wheels” on the clinical teams – they are important members of the

teams with important responsibilities for gathering information, developing

a differential diagnosis, suggesting investigations, weighing the evidence for

and against the treatment options, and communicating with the patients and

their families. Although it is helpful for them to observe their teachers

interacting with patients, they usually learn more by “hands on”

involvement. You will need to assess each student’s abilities early in the

rotation to determine how much you can safely ask them to do. It is a legal

requirement that all patients seen by students must also be seen by the

student’s supervisor.

Some tips for fitting a student or resident into a busy practice:

▪ Share the teaching with others – your partners and colleagues and

community organizations such as your local lab tech (to improve

skills in venipuncture), home care coordinator, the local Health Unit,

hospice, social worker or physiotherapist. Doing a few house calls

with the local public health nurse can be a valuable eye-opener.

▪ Schedule other learning activities for the learner, e.g., preparing a

presentation, writing an article on a common health problem for the

local newspaper, speaking to a community group or to students at

the local grade school or high school. Preparing patient handout

material would be helpful for your practice. It may be valuable to

have the student conduct a chart review on a common condition seen

in your practice. This will be good learning for you as well as the

student. You can keep a list of popular projects from which the

student can choose. Providing Internet access will help the student

find background material.

▪ Sending a student to do a comprehensive work-up of a patient at

home will provide insights into the social context of a patient’s illness.

▪ Take students to staff meetings and other hospital or practice committee

meetings.

L We are proud to be a training site for medical students and residents.

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ORIENTATION – SHARE EXPECTATIONS:

ou can mail or email your student or resident before he or she

arrives to provide information about your practice and community

and what they can expect when learning with you. Ask the learner

to fill you in on their background and especially about what they

have done so far in the clerkship or residency. It is helpful to provide a map

to your office and to let them know where and when to show up on the first

day (including where they can park if they are coming by car).

When the student or resident first arrives, find out about their previous

clinical experiences and their special interests. What do they hope to learn

from you? What areas of medicine do they find difficult or confusing? What

skills do they want to practice, e.g., using the ophthalmoscope, doing pelvic

exams, doing procedures, etc.? Students are often reluctant to admit any area

of weakness until they feel more comfortable with you and trust that you

won’t use this against them in their evaluation. See Appendix A for an

example of a form you can use to gather this information from the student

ahead of time.

Next, spend a few minutes orienting them to the office or hospital. Introduce

them to your staff. Let them know how they will be assessed. Make sure

they understand what is expected of them, e.g., responsibility for patient

care, punctuality, dress code etc. Making these issues clear at the start can

prevent problems later on. Tell them about your community and the special

attractions they might enjoy during their time off. Find out if they will be

absent for holidays, conferences or other approved activities. You may find

it helpful to have a checklist or handout for the student or resident outlining

the key points in the orientation. For an example of a checklist, see

Appendix B.

Some suggestions to help with orientation in a busy practice:

▪ Ask your staff to assist with the orientation, e.g., tour of the office

(including where to keep lunch), overview of the community (e.g., local

restaurants, fast food outlets, opportunities for recreation, etc.), dress

code.

▪ A good orientation will save a lot of time in the long run. One study

showed that it took students up to two weeks to figure out how to focus

their work-ups, write up charts, and present cases.3

▪ Don’t try to cover everything on the first day – it may be overwhelming.

The important thing is for the new learner to feel welcome and have a

clear idea of how they will fit in.

3 Kurth RJ, Irigoyen M, Schmidt HJ: A model to structure student learning in ambulatory

care settings. Academic Medicine. 1997;72:601-606.

Y

An orientation can help get your learner off to a good start by clarifying expectations and preventing or correcting misconceptions. It will save time in the long run.

Your staff can be a big help in the orientation.

Make sure your receptionist and other staff are aware when a student or resident will be with you so that they can adjust your schedule, book some patients for them and welcome them when they arrive.

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▪ If you use an electronic health record, learners will need an orientation to

it. Provide tips on how to use the EHR in ways that include the patient.

A short manual on the EHR can be invaluable.

▪ If you teach students or residents regularly, it will save time to develop a

brief handout about your office and community, your approach to

teaching and supervision and your expectations of learners. Then you

can spend your time responding to questions after they have reviewed

the handout.

▪ Some practices have learners go through the office as a patient,

registering with the receptionist, sitting in the waiting room, being taken

to an examining room by the nurse and then going to the lab. This

provides a first hand experience of what it is like to be a patient in your

office.

▪ Have the student write out 5-6 objectives they have for their time with

you. Introduce the idea and give them a few days to complete. Then post

the list for everyone who will be teaching the student to see.

SELECTION OF PATIENTS AND PRIMING:

team “huddle” at the start of each clinical session is often helpful

– the physician, nurse and student gather around the patient list to

identify which patients a student will see and briefly outline the

reasons for their visit. If the student has time, he or she could

quickly look up information about the patients’ problems in order to be

better prepared. Identifying patients and their problems the night before

would give students a strong incentive to prepare. The “huddle” is also an

opportunity to clarify the nurse’s role with each patient and whether of not

additional equipment might be needed for particular visits. Often the nurse

has had contact with patients between visits and this is an opportunity to

share that information.

While most patients are suitable for involvement with students, there are

some issues worth considering. First, some patients prefer not to see a

patient – they may have a very difficult personal issue to discuss; they may

have seen students several times before and need a break from teaching; they

may be in a rush and not have the extra time required to be seen by a

student. Next, the student’s ability needs to be considered. An inexperienced

student at the start of clerkship may be overwhelmed by a patient with

several complex problems and may not be able to deal with some patients

who are abrasive or uncooperative. It may be best to start these students with

more straightforward cases, e.g., friendly patients with typical examples of

one or two problems.

“Priming” (a.k.a. “briefing”) involves spending a minute or two preparing

the student for the encounter. Ask them to consider their goals for the

A Without priming, students may spend too much time with patients collecting every piece of information that might be important. They need guidance in preparing for the encounter: help them define what questions they will need to be able to answer at the end of their assessment and tell them how much time they have.

More tips for incorporating students into your practice, including the “wave” schedule are HERE.

CLINICAL TEACHING TIPS PAGE 9

interaction – what questions they need to be able to answer at the end of

their assessment, e.g., what is the differential diagnosis, or what

investigation or management is indicated. Be clear about your

expectations re how much time they should spend doing the

workup and what they should focus on, e.g., “Take 20 minutes

to find out all the issues on the patient’s agenda.” Or,

“Determine the patient’s priorities and explore the top two.” Or,

“Take a detailed history of these two issues and conduct a

targeted physical exam.” Or, “Come up with a differential

diagnosis and a plan for investigation and management.” Once

you have primed the student several times, this process becomes

much quicker. Experienced students and residents will soon be

able to prime themselves by reviewing the chart before seeing

the patient.

If you have a slow student (they might be very knowledgeable but

overly meticulous, disorganized or writing copious notes), provide them

with clear guidance:

▪ Give them a definite time limit: “Take 15 minutes to conduct the history

and physical and think about the investigation and management. But

come out with whatever you have in 15 minutes.”

▪ If the student does not come out, go into the room and join them.

▪ Advise them to take briefer rough notes.

But remember – the patient might have a very different idea about the

purpose of the visit. Remind the student that they might need to change their

plans after asking the patient about their concerns and priorities.

ONGOING NEEDS ASSESSMENT:

his is one of the most important teaching tasks and one that is often

neglected. It simply means finding out what the student is good at

and what they need more help with – this is important so that you

can concentrate your teaching on what they need rather than on

what you like to teach whether they need it or not. Teachers can guess at the

student’s needs based on other students they have taught at the same level

but student variability is so great that it is essential to assess each student

individually. You can begin the needs assessment during your initial

orientation of the student but you will continue to learn about the student’s

needs during every case presentation and discussion with the student.

Recognizing that the needs assessment is ongoing encourages you to update

your goals for the student as you learn more about their strengths and areas

that need more attention.

T

The needs assessment is key to effective teaching. It helps you focus your teaching on what the student needs to learn rather than repeating what they already know.

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DURING:

AUTHENTIC

RESPONSIBILITY:

▪ Students may wish to observe you with patients on the first day,

especially early in the clerkship. But they will learn more by being

actively involved in working-up patients on their own followed by a case

presentation and discussion. If the first morning is quite hectic, have

your staff provide an orientation to the practice and then have the student

actively observe you with patients. Then review their background and

your expectations at noon and get them more involved in seeing patients

on their own in the afternoon. It is important that they have real,

meaningful responsibility for patient care. They need to be doing more

than simply practicing their interviewing and physical exam skills –

what they do should make a positive difference to the care of patients.

▪ Give them relatively straightforward cases to start with. Observe them

for a few minutes with each case until you feel confident in their ability

to do a good work-up on their own. Make sure they realize the

importance of being honest about any areas of ignorance and that your

relationship is comfortable enough that they will tell you. Otherwise you

may not be aware of important gaps in their assessments. Most students,

especially in the second half of the year, are excellent data collectors.

Where they need most help is with differential diagnosis, investigation

and management. But there are a few weak students who will need a lot

of careful monitoring throughout the year.

▪ Your nurse or staff should check with patients for consent to see a

student. Suggest that they ask in a positive way, e.g., “How would you

like to be a teacher today?” or “Would you be willing to see our student

to help him/her learn more about medicine? We are involved with

teaching in order to encourage new doctors to come to our community.”

Make sure your staff is aware of your enthusiasm for teaching and try to

get them enthusiastic too. This enthusiasm will rub off on patients. If the

staff sees this as an added chore, then they will convey a negative

attitude and patients will refuse to see students. Make sure you thank

patients for being involved in the teaching program.

▪ Focus on one teaching point with each patient. In clinical teaching in a

busy office, less is more – they will learn more in the long run by

focusing rather than hearing a long dissertation on your favorite topic or

being subjected to your war stories. And it will be quicker.

Students learn best by having real responsibility for patient care combined with tailored supervision. All patients seen by students must also be seen by a physician.

Choosing Wisely Canada is an excellent resource for guiding our decisions about care. See “The Lists” tab for a list of 11 things family physicians and patients should question.

“Less is more!”

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▪ Have the student record the note for the visit. Provide clear

guidelines for charting so that you don’t have to re-do them.

▪ Students can make follow-up phone calls to patients about

the results of lab tests or to find out how they are doing.

Patients like the extra attention and will be more willing to

see students again.

▪ Use handouts. Provide access to the Internet and bookmark

good websites. Note the excellent online library resources

available for all faculty members from your medical school,

e.g., Differential Diagnosis in Primary Care, Current

Medical Diagnosis and Treatment, the Cochrane Library,

Clinical Evidence, Current Practice Guidelines in Primary

Care, Harrison’s Online and hundreds of individual journals

such as Canadian Family physician, the New England Journal of

Medicine, JAMA, Lancet, Journal of Family Practice, Family Practice.

▪ The Canadian Library of Family Medicine has many valuable resources,

e.g., a list of journals on family medicine worldwide indicating which

ones are available full text on PubMed Central. Click HERE.

▪ If you don’t know the answer to a clinical question, show them how you

deal with uncertainty, e.g., looking up the answer in a textbook or on the

Internet. If you don’t need the answer right away, consider having both

of you look up the answer and sharing results the next day. Or, you

could take turns.

▪ The student will see some patients while you see others. See the “wave”

schedule HERE. If the patient you are seeing has interesting clinical

findings, bring the student in briefly to demonstrate.

▪ If you get way behind, tell the learner to work on charts, or on a project,

or to read up on some of their cases until you can catch up. Let the

student know at orientation that you might use this strategy so they are

not caught off guard and will be able to use the time effectively.

GRANTING RESPONSIBILITY FOR PATIENT CARE:

New clinical teachers are often unsure how much responsibility to give to

their learners. They know that students learn best when they must make their

own decisions about patient care rather than simply following the

suggestions of their teacher. Granting too much responsibility may

overwhelm a resident who is not ready and places patients at risk. But not

granting enough responsibility holds residents back and reduces their

learning. Residents need to learn how to apply their skills when they are

facing the stress of being responsible for the well-being and the lives of their

patients. But preceptors also recognize their responsibility to assure patient

safety. This balancing act can be challenging. Often, clinicians assume a

level of competence in their learners based on their year of training.

Although that approach provides a rough estimate of a learner’s capabilities,

it is often inaccurate.

The Canadian Library of Family Medicine has lots of valuable resources for teachers HERE.

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Recently, Olle ten Cate (2006)4 has proposed the concept of entrustable

professional activities (EPAs) to guide clinical teachers in this important

decision. There are three overlapping sets of abilities or traits that need to be

considered in granting increased responsibility.

All EPAs will require appropriate personal qualities and basic clinical skills;

specific EPAs will relate primarily to context and content specific abilities.

Typically, an EPA will be granted in stages, e.g., taking a history, then

performing a focused physical examination, then developing a differential

diagnosis and finally generating a treatment plan. Different domains of

practice will have their own EPAs since they require different specific

abilities.

1. Personal qualities:

Three personal qualities are essential to protect patient safety before

allowing residents to see patients independently – truthfulness,

conscientiousness and discernment (Kennedy et al, 2008)5. Most

residents are conscientious and most will be truthful unless their teachers

punish them for being honest about their uncertainties and their inability

to conduct impossibly complete assessments in the short time available.

Most residents are not very accurate in self-assessment but should be

able to sense when they need to slow down, rethink their assessment or

ask for help. Medical education tends to encourage a “macho” approach

4 Ten Cate O: Trust, competence and the supervisor’s role in postgraduate training. BMJ.

2006;333(7571):748-751. 5 Kennedy TJT, Regehr G, Baker GR, et al: Point-of-care assessment of trainee

competence for independent clinical work. Academic Medicine. 2008;83(10 Suppl.):589-

592.

Basic

clinical

skills

Personal

qualities

Context &

content

specific

abilities

CLINICAL TEACHING TIPS PAGE 13

of trying to get by without needing any assistance. It is important for

preceptors to dispel this false ideal and replace it with the ideal of getting

help when needed to assure patient safety.

• Truthfulness: Trust that what they said or recorded are accurate

reflections of what they actually did. They are honest about their

confusion or lack of knowledge. They do not modify their

presentations simply to impress their teacher.

• Conscientiousness: They go the extra mile for patients when

necessary and take responsibility for their actions. They don’t cut

corners in ways that might compromise patient welfare. They do

what is right even when no one is looking.

• Discernment: They are aware of their limits and when they need

help and will take appropriate steps to get assistance. They are

effective at seeking out assessment, knowing that it is important

for their own learning. Patient welfare is their first concern and is

more important than “looking good” in the eyes of their

supervisor. They are aware of personal beliefs, attitudes and

emotions that may impair their judgement.

2. Basic clinical skills:

Basic clinical skills are essential for adequate assessment of patient’s

problems and concerns. Effective patient-centred interviewing is important

to set patients at ease and involve them in setting the goals for the visit and

incorporating their values and preferences in treatment. Unless patients are

comfortable with the resident they may not disclose some of their concerns.

And, if they are not involved in decisions about management they may not

follow through on the treatment plan. Skills in history taking, physical

examination and clinical reasoning are obviously essential for safe patient

care. The following description of competencies outlines the many abilities

that teachers look for in their residents but their final decision is more often

based on a gut reaction than on a detailed analysis of this long list of

competencies.

Interviewing: They apply the patient-centred clinical method in all

consultations with patients. They are particularly effective in putting patients

at ease, not interrupting the patient’s opening monologue, using open-ended

inquiry, reflective listening and empathy. They explore the patient’s unique

illness narrative to understand their ideas about what might be causing their

concerns, how they feel about them, how they affect their daily function and

what they hope the physician will do to help them. They involve patients in

setting the goals for the encounter and in decisions regarding investigation

and treatment. They use the electronic medical record to enhance

collaboration with patients.

• History-taking skills: They quickly review the problem list,

medication list and last visit note before seeing the patient. They

determine all of the patient’s concerns and, together with the

CLINICAL TEACHING TIPS PAGE 14

patient, decide whether or not they can all be addressed at this

visit and then set priorities. They explore each concern

appropriately recognizing when it is important to supplement the

patient’s history with information from family, other physicians

and the medical record. They recognize which historical features

have high predictive value. Their data gathering is guided by

their search for a differential diagnosis as well as to clarify

treatment issues, e.g., simply knowing the diagnosis is not

adequate for planning management; treatment will be quite

different for a chronic stable condition compared to an acute

exacerbation. They are also skilled at exploring patient’s

narratives and integrating information related to disease with the

meanings derived from the narrative.

• Physical examination skills: Their physical examinations are

organized and conducted skillfully. They are able to distinguish

normal variants from abnormalities.

• Clinical reasoning: They are able to apply both analytic and non-

analytic approaches to clinical reasoning and recognize the

inherent risks of error of each approach. They consider both

probability and payoff in developing an appropriate differential

diagnosis and recognize red flags. They are able to manage

uncertainty appropriately and can recognize when it is

appropriate to reassure the patient or use time as a diagnostic tool

or when it is important to investigate more intensively, or to act

quickly or refer. They are able to prioritize problems. They

recognize that patients consult physicians for many reasons, not

just disease and can modify their approach to address the

particular needs of their patients. They are able to make

appropriate decisions regarding their patients’ predicaments even

when they cannot make a definitive diagnosis.

• Case presentation: Their case presentations are clear, well-

organized and include the key information on which they based

their decisions including important negative findings. Their case

presentations also include a summary of the patient’s illness

experience and how patient preferences are incorporated into the

treatment plans.

• Record keeping: Their medical notes are a concise, well-

organized and accurate record of their findings and decision-

making.

3. Content and context specific abilities:

The first two sets of qualities and abilities are somewhat general and apply

to a wide range of patients and their problems. But the third domain is

highly content and context specific. For example, residents may be very

skilled in the assessment and treatment of patients with asthma but limited in

their abilities with patients with diabetes. This is largely a reflection of their

CLINICAL TEACHING TIPS PAGE 15

prior experience with patients with specific conditions. Because of this, it is

important for clinical supervisors to assess their residents’ abilities with a

range of clinical presentations and not assume that, because they were

skilled in managing the last patient with angina, they will be equally skilled

with the next patient suffering with dementia. However, once the supervisor

has seen a resident perform well in managing several patients with a range

of conditions, it is reasonable to assume that they will do well with the next

patient. As long as the resident will seek assistance when they feel out of

their depth, then patient safety can be assured. The supervisor will take into

account a number of factors related to the patient when considering how

much independence is appropriate. The seriousness of the patient’s

condition, complexity of multiple co-morbidities, challenging behavioural or

social factors may all merit more careful supervision and affect the level of

responsibility given.

A competent resident will demonstrate the following abilities:

• They are able to apply disease-specific knowledge in assessment

by appropriately modifying their approach to the history and

physical examination.

• They are skilled in applying principles of the behavioural

sciences appropriate to the patient’s presentation.

• They are skilled in applying their competencies in different

settings – in a family practice office, in the emergency

department, on a hospital ward or in a patient’s home. (Skill in

one setting does not necessarily transfer to skill in another.)

• They are skilled in caring for patients across the life cycle and

across diverse populations.

RELATIONSHIP BUILDING:

his is another vital skill – the research indicates that the teacher-

learner relationship is the single most important component of

clinical supervision. Continuity over time is very helpful in the

development of an effective relationship. Behavioural change can

occur relatively quickly as a result of supervision whereas changes in

thinking and attitude take longer. This is particularly important where there

are frequent changes in supervisor6. It is appropriate to involve your

colleagues as co-teachers to fill in when you are away or to provide

additional experiences that will enrich the students’ learning. But, it is

important that the bulk of their time will be with one teacher. Students need

to feel comfortable with you and need to respect your clinical skills and feel

that you care about their learning. Unless the climate is comfortable,

6 Kilminster SM, Jolly BC: Effective supervision in clinical practice settings: a literature

review. Medical Education. 2000;34:827-840.

T

Your relationship with learners is the single most important component of clinical supervision.

See the article on the role of the student-teacher relationship in the formation of physicians – HERE.

CLINICAL TEACHING TIPS PAGE 16

students will be less willing to say what they really think and will be hesitant

to ask questions in case they sound like “dumb questions”. Let them know

that you think the only dumb question is the one the student wonders about

but never asks. You are a powerful role model for every student you teach

and they will tend to pick up your attitudes and values without realizing it.

This is even more important than all the facts and skills they learn from you

and has a great bearing on the kind of doctor they become.

CASE-BASED TEACHING AND LEARNING:

▪ Provide brief teaching before, during, and after each patient visit

focusing on one main teaching point. Jot down a note about any other

points you would like to make and review these later in the day, e.g.,

over lunch or in the car on the way to the hospital.

▪ Encourage students to keep a record of questions to review when you

both have more time for discussion.

▪ Encourage students to use your library of books, journals, and Internet

access to learn from each case on their own. Tell them you expect them

to spend some time in the evenings reviewing cases and reading around

the problems they presented.

CASE PRESENTATION:

▪ Presenting a case in a well-organized manner that includes only the

information needed for assessment and management is a complex

skill that is gradually learned by most clerks as they progress through

the clerkship. One of the challenges for students is the lack of any

standard format – every teacher seems to want a different approach.

Most teachers like to start with basic demographic information: e.g.,

“Mary Smith is a 64-year-old married white female…” But there is

little agreement about what comes next. Some teachers prefer to have

the student present a complete problem list followed by a list of

presenting complaints. Others want to hear more about the personal

situation of the patient, e.g., living situation, job etc. Some like a

problem-oriented format, others a more traditional outline. Let the

student know how you would like the case to be presented. Having a

short handout for the student is very helpful.

▪ Freeman has developed a patient-centred case presentation that is

valuable for reinforcing the patient-centred clinical method by giving

“primacy to the patient and the total experience of the illness and

associated pathology.”7 Suggesting to students that their case

7 Freeman TR: The case report as a teaching tool for patient centered care. In: Stewart M,

Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR: Patient-Centered

Be clear about how you want cases presented. See Appendix D for a helpful handout.

Encourage learners to keep a list of questions for discussion with you or for their own reading.

CLINICAL TEACHING TIPS PAGE 17

presentations should include information about the patient’s life

situation, their ideas about what is wrong with them and their

preferences for management gives a strong message about the

importance of using a patient-centred approach in their care.

▪ While listening to the case presentation, you may quickly

recognize a familiar disease pattern. Or you may be developing

hypotheses about the patient’s diagnoses and considering what

should be done next. You may have many questions to explore

your differential diagnosis but it is best to save these until after

the presentation. From the students’ perspective, the ideal

presentation is one that is not interrupted too often –

interruptions may confuse them and are often seen as criticisms

of their presentation.8 Students also tend to downplay

uncertainty, considering it a sign of weakness, whereas teachers

need to know when the student is uncertain in order to explore

these areas in more detail. Interruptions may be valuable to help

the student stay on track or get back on track, to explore

important areas omitted by the student, and to make a teaching

point. Be careful that these “detours” don’t sidetrack the

presentation leading to major sections being left out, e.g., when a

student presents a patient with diabetes, it is tempting to launch into

your favorite teaching script on diabetes. As time passes and you start to

get behind schedule, you may decide to proceed to seeing the patient

before the student has told you about her chest pain and depression.

▪ It is often valuable to have students present their findings in front of the

patient.9 This saves time, many patients like it better, and it may provide

information about the interaction between the student and patient and

facilitates teaching about clinical skills. It also gives the patient an

opportunity to correct any misinformation and reassures the patient that

you have heard the whole story. But, caution the student to warn you if

the patient has very personal issues or a potentially serious condition. In

this case, you might wish to discuss the case first away from the patient.

Sometimes it is useful to discuss the case separately from the patient to

facilitate an exploration of the student’s clinical reasoning. Also, some

students lack confidence and feel very uncomfortable presenting in front

of patients. In this case it may be best to let them present privately until

Medicine: Transforming the Clinical Method. 3rd edition. Abingdon, Oxon, OX: Radcliffe

Medical Press, 2014. 8 Lingard L, Schryer C, Garwood K, Spafford M: ‘Talking the talk’: school and

workplace genre tension in clerkship case presentations. Medical Education.

2003;37:612-620. 9 Rogers H, Carline JD, Paauw DS: Examination room presentations in general internal

medicine clinic: patients’ and students’ perceptions. Academic Medicine. 2003;78:945-

949.

Consider having students present their findings in front of the patient.

CLINICAL TEACHING TIPS PAGE 18

they gain confidence. But, they usually get more comfortable presenting

in the presence of the patient by doing it.

▪ Students should be able to present cases without reading their clinical

notes. But, novice learners may need to use cue cards to keep themselves

organized and not leave out important information. It is important for

students to learn to present in a manner that “makes the case” for their

diagnosis rather than in the same order in which they collected the data.

For learners who have trouble providing a concise case presentation, you

could suggest: “Summarize the patient’s situation in three sentences.”

This can be a great strategy for getting them to hone their skills in case

presentation and prepares them for telephone case presentations that

often need to be very brief.

▪ See Appendix D – Format for Case Presentation.

DISCUSSION & COACHING:

Traditional clinical teachers are powerful, sometimes intimidating, authority

figures. They seem to believe that fear is needed to motivate students to try

their best. But most students and residents are already trying their best and

frightening them decreases their learning. It is more effective to tell your

learners that you will act like a coach helping them to fine tune their skills.

The coaching metaphor is helpful in framing feedback as guidance rather

than as marks on an exam. No one would hire an expensive golf coach to

only tell them nice things about their golf swing. We would all want to know

how we could make our swing better.

This approach emphasizes the learner’s strong points and reframes their

weaknesses as learning goals or things to work on rather than as deficiencies

or personal faults. Start by asking the learner what they think they did well.

Often they are hesitant, feeling embarrassed that it will sound like bragging.

Encourage them by explaining the importance of developing skills in

reflection and self-assessment so that they can continue to assess their

learning needs after graduation. After their comments, add your own

description of the effective behaviours that you observed. Some students and

residents are overly critical of themselves and may not be aware of the skills

they have achieved so your genuine praise will be very encouraging. Next,

ask the learner to describe one or two things they might have done even

better. Then add your own comments. Often this will simply be affirming

what the learner said and together coming up with a plan for how you can

help them to improve.

Additional tips for coaching:

• You can focus on one aspect of the interview for a day such as the

initial gathering of all the patient’s concerns (“Anything

See yourself as a coach helping your students and residents to hone their skills by praising their good performance and giving them tips on how they can be even better.

CLINICAL TEACHING TIPS PAGE 19

else…anything else…”) Or focusing on how well the

resident explains the treatment to patients. Or how well

they find common ground with patients. Focusing on one

skill for a whole day fits nicely with what we know about

deliberate practice – concentrating on a very specific task

and repeating it over and over again until it is mastered.

• Ask “What else could this be?” when working with strong

residents who have a good knowledge base and excellent

clinical reasoning skills. Sometimes these residents get so

confident that they start taking too many short cuts. Their

experience is usually not good enough to be relying solely

on pattern recognition.

• Use a monitor to view a resident-patient interaction. This is a good

strategy for giving the resident a greater sense of being on their own

and being responsible for patient care decisions. It is particularly

valuable for monitoring communication and relationship skills.

• Address issues dealing with uncertainty. It is important to help

residents, especially in 2nd year, learn how to deal with the

discomfort of decision-making in conditions of uncertainty. They

need to learn how to differentiate uncertainty related to their own

learning needs from uncertainty inherent in the patient’s condition

and they need to recognize when they need help. They need to learn

how to evaluate the seriousness of a patient’s condition even when

they cannot make a diagnosis.

• Use “What if” questions to challenge strong residents, e.g., What if

this patient with pneumonia had been travelling in California or

Arizona recently? What if this was a rural setting? What if the

patient was a child, or a senior? What if you were practicing in a

remote location?

• Encourage learners to review the chart before seeing patients so that

they are better prepared for the encounter. This can be very helpful

especially for clerks or when the patient is complex and new to the

resident or for residents who are struggling.

• Remind residents to tell patients when to return for their next

appointment even for stable chronic conditions. Residents may need

to be reminded to consider all patients in perpetual follow-up even if

the next appointment is in one year.

• Demonstrate aspects of the P/E on the resident e.g., how hard to push

over the sinuses to determine tenderness or over costochondral

junctions to diagnose costochondral pain.

• Ensure that the patient-centred clinical method is included in all case

presentations e.g., including FIFE along with the HPI. If discussion

of communication skills is left out of the case presentations it gives a

message that they are not important.

• Give the residents more responsibility. They will learn more,

compared to when you take over, if they have to take more

CLINICAL TEACHING TIPS PAGE 20

responsibility for decisions about patient care and not feel too

comfortable knowing their teacher will bail them out. Pushing the

resident to make his/her own decisions teaches them a lot more than

if they had just watched the teacher passively.

• If there is time, consider providing an immediate opportunity for the

learner to practice a skill they have just learned, e.g., if you have

coached them in providing instructions to a patient about

management, it will help to consolidate their learning if you give

them another chance to practice these patient education skills with

you playing the role of the patient. This may take only 2-3 minutes

but will pay dividends in their learning. Another valuable use of role-

play is rehearsal just before the learner sees a patient, e.g., you can

coach them about how to ask about treatment adherence or about

how to break bad news and then ask them to try it out with you role-

playing the patient.

THE ONE-MINUTE PRECEPTOR MODEL:

linical teaching must be quick. There is reasonable evidence that the

“One-Minute Preceptor Model” (also referred to as the “Five

Microskills” Method) is an effective approach.10 They are a set of

basic teaching skills that can be used when reviewing a case that the

learner has just seen. They provide a simple set of skills that are effective in

many teaching situations. But they should not be used as a recipe – in some

situations, other skills should be used. In this monograph I have incorporated

these five microskills into a more comprehensive framework. Some or all of

these skills can be applied after a student has presented a case to enhance

their learning:

1. Get a commitment – this means getting the student to

commit themselves to an opinion about the diagnosis or

about investigation or management. They need to feel

comfortable enough with you to be able to “stick their neck

out” in making the commitment. By making a commitment,

they feel more responsible for their own learning and are

more motivated to learn.

2. Probe for supporting evidence – Ask the student to provide a

rationale and evidence for their commitment – how they came to

their conclusions. This provides important insights into their

knowledge base, reasoning skills and learning needs. This is an

important part of your ongoing needs assessment of the student. Of

course, you will also be forming an opinion about the student’s

10 Aagard E, Teherani A, Irby DM: Effectiveness of the One-Minute Preceptor Model for

Diagnosing the Patient and the Learner: Proof of Concept. Academic Medicine.

2004;79(1):42-49.

C These FIVE microskills can be performed quickly after the student has presented a case. They improve the effectiveness of clinical teaching. Click HERE.

CLINICAL TEACHING TIPS PAGE 21

strengths and weaknesses during the case presentation and

subsequent questioning.

3. Teach general rules – what is the “take home” message from this

experience. E.g., “When a patient’s hypertension is poorly

controlled, ask about adherence to medication and alcohol intake.”

Or it may be a recommendation to read up on a particular topic.

General rules enhance the likelihood that the student will be able to

apply what they have learned to another similar case. Sometimes

there will be time to provide a mini-lecture – a brief outline of a

clinical pearl that may be hard to find in a textbook. Having a file of

articles or notes allows you to provide handouts to reinforce and

amplify what you have taught. It is also helpful to have good

websites bookmarked for later reference by the student. Having a

small up-to-date library of core texts is also valuable for reference

when clinical questions arise although this is less necessary now that

so many online resources are available including whole textbooks

through university library systems and the Canadian Medical

Association.

4. Reinforce what was right. Students are sometimes unsure of

themselves, even when they are right. They may be unaware of their

strengths. It helps them to have their knowledge and skills affirmed.

5. Correct mistakes. These last two important elements of the One-

Minute-Preceptor model are further discussed in the section on

“Discussion and Coaching” above and in “More About Feedback”

below.

See the section on questioning below for examples of how to ask about the

student’s commitment and underlying reasoning.

For another video demonstrating the microskills approach,

click HERE.

Some teachers would add two more skills – “set expectations”

and “reflection and integration”. Set expectations means being

clear about what you expect the student will learn over the

whole rotation and also setting specific expectations before

each patient – “priming” the student before they go in to see

the patient. Reflection and integration are important to

encourage the student to think about their own learning and to

reflect on their experiences over the day or over several days and to put their

learning into perspective. This is also an opportunity to think about their

learning plan – other things the student or resident needs to learn about.

CLINICAL TEACHING TIPS PAGE 22

The SNAPPS11,12 Framework:

his framework is particularly useful for a confident student or

resident who is ready to take more responsibility for their own

learning. In this approach the learner takes control of the discussion

around the case presentation. SNAPPS is an acronym for the

following 6 steps:

S – Summarize briefly the history and findings. This should take no more

than 50% of the time of the presentation and discussion.

N – Narrow the diagnosis or management to 2-3 relevant possibilities –

make a commitment.

A – Analyze the reasoning by reviewing the findings or examining the

evidence – compare and contrast the possibilities.

P – Probe the preceptor by asking questions about uncertainties.

P – Plan management.

S – Select a case-related issue for self-directed learning.

Some teachers would add another S – Solicit feedback.

As you can see, there are many similarities with the One

Minute Preceptor Model – except in this approach, the learner

leads the process and the teacher may be relatively silent until

probed about the learner’s uncertainties. However, the teacher

may be quite actively involved in the conversation if the

learner is struggling, e.g., in guiding the learner to consider other possible

diagnoses or management options or in correcting any errors. The teacher

may need to coach learners initially but should quickly encourage them to

take over the lead role. The teacher’s main role is to act as a guide.

MORE ABOUT FEEDBACK:

eedback is essential for learning. Of all the techniques a teacher can

use, feedback has the greatest effect on learning.13,14 Without

feedback, the learner can practice over and over again but may never

know if they are doing it right. Feedback is information that

highlights the difference between the actual and intended results. Of course,

when the actual and intended results are the same, the feedback should be

congratulatory. Another valuable framework for providing feedback, from

the Institute for Healthcare Communication, is WWW.EBY - “what went

11 Wolpaw TM, Wolpaw DR, Papp KK: SNAPPS: A Learner-centered Model for

Outpatient Education. Academic Medicine. 2003;78:893-898. Click HERE for the article. 12 The last S was added by students in the course on Teaching and Learning in the Health

Sciences taught by Wayne Weston for the Graduate Studies Program at the University of

Western Ontario, 2007. 13 Hattie J, Timperley H: The power of feedback. Review of Educational Research.

2007;77:81-112. 14 Norcini J: The power of feedback. Medical Education. 2010;44:16-17.

T

F

Feedback is essential for learning. Imagine trying to learn archery and never knowing where your arrows landed!

Click HERE for an example

CLINICAL TEACHING TIPS PAGE 23

well” and “even better yet”. This puts a positive spin on those areas that still

need improvement. Also, it emphasizes the fact that, even if the behaviour

was done well, it often could be even better. See the London Deanery

website HERE for valuable tips on how to give feedback.

Guidelines for providing feedback:

▪ Feedback should answer three questions:

o Where am I going? (What are the goals?)

o How am I doing? (What progress is being made towards the

goals?)

o Where to next? (What activities need to be undertaken to

make better progress?)

▪ Feedback can be very brief, e.g., “I really liked the way you explained

the diagnosis, avoiding jargon and giving the patient lots of opportunities

to ask questions.” And it should be done frequently. The research

indicates that students and residents don’t get enough feedback.

▪ Time feedback as close to a performance as possible so that you and

your student can still remember the details of what happened.

▪ Ideally, feedback is part of a conversation between the preceptor and

learner. Both should be actively involved in exploring what happened,

what made it effective and what could have been even better. Start by

asking the learner to assess themselves. Most students will be harder on

themselves than you will be and that makes it easier for you to provide

honest feedback. Also, it will tell you how aware they are of their

strengths and areas needing improvement. Unfortunately, weak students

often think they are better than they are because of poor insight.

▪ Use notes to help you recall the points you wish to make – this helps you

to be more specific. E.g., “When the patient said …. you

changed the subject and later the patient brought it up again.

Then you picked up nicely on his question and expressed

empathy by saying…” By recording exactly what was said

you are able to remind the resident about the interaction.

▪ Comment favourably on what was done right. They may not

realize how good it was. Reinforcing this behaviour makes it

more likely they will keep doing it.

▪ Describe the observed behaviour not the person. It is usually

best to avoid making assumptions about motives – just

describe what you observed. In describing their behaviour, be

as specific as possible. Don’t “beat around the bush” in an

attempt to sugar coat areas needing improvement – the risk is that

they will not understand your comments and not realize they had made a

mistake. Or, they may know by your tone of voice or facial expression

that they did something wrong but not know what it was.

▪ End the feedback with a discussion about what the learner can do to

improve any deficiencies. Start by asking the student what ideas they

have for further learning.

“Constructive feedback is the art of holding conversations with learners about their performance.” - Mohanna K, Cottrell E, Wall D, Chambers R: Teaching Made Easy. 3rd edition. Oxford: Radcliffe Medial Press, 2010.

CLINICAL TEACHING TIPS PAGE 24

▪ Follow up with positive feedback and praise when improvements are

noted.

▪ Sometimes it helps to be explicit about providing feedback because

learners often underestimate the amount of feedback they actually

receive, thinking it was just a discussion. You could say, “Let’s discuss

how that last interaction went. I will give you some feedback about what

I think but I’d like to work together with you and find out first what you

think.”

Constructive feedback has several identifiable qualities, including:

Quality Good example Poor Example

It is descriptive

not evaluative

"I notice you didn’t make much eye

contact with the last patient during

the interview."

"You are not

interested in patient

care."

It is specific rather

than general

"You were able to convey empathy

and understanding during the

interview, e.g., when he looked

upset discussing his recent divorce,

you…"

"You did a good

job."

It is focused on

issues the learner

can control

"When taking the history, it would

help to speak slower and check for

understanding."

"My patients cannot

understand you

because of your

accent."

It is well-timed Provided regularly throughout the

learning experience, and as close as

possible to the events stimulating

the feedback.

Provided only at the

end of the rotation.

It is limited in

amount

Focused on a single, important

message.

Learner

overwhelmed with

information.

It addresses

learner goals

Addresses learning goals identified

by the learner at the beginning of the

rotation.

Learner's goals are

ignored.

The University of Edinburgh provides a video demonstrating feedback using the ALOBA (Agenda-Led Outcomes-Based Assessment) model HERE.

Columbia University provides a quick summary of the Ask-Tell-Ask Model of providing feedback HERE.

CLINICAL TEACHING TIPS PAGE 25

MORE ABOUT QUESTIONING TECHNIQUES:

uestions are the teachers’ primary tool for stimulating thinking in the

learner. Some of the most useful questions you can ask are the

following:

▪ “What do you think is going on with this patient?”

▪ “How did you reach that conclusion?” Or “What’s the evidence for that

conclusion?”

▪ “What was it about the patient’s presentation that led you to that

diagnosis?”

▪ “What else could it be?”

▪ “How is this affecting the patient’s life?”

▪ “What are the patient’s ideas about the problem?”

▪ “What are the patient’s expectations for this visit?”

▪ “What do you think we should do next?”

▪ “How would you explain that to the patient?”

▪ “What are you feeling right now about this patient?”

”What is it about the patient that makes you feel this way?”

▪ “In what ways can you be helpful and comforting to the patient?”

Common errors in asking questions:

▪ Interrupting the student’s case presentation too often with questions

(students may find it distracting and intimidating).

▪ Asking questions that only require memory but not thought, e.g., “What

is the starting dose of pravastatin?” This is a rather trivial question that

can easily be looked up.

▪ Playing “Guess what I’m thinking.” This happens when you are

perceived as asking for one particular answer to a question – you are

asking the student to guess the answer you are thinking about rather than

to probe their understanding.

▪ Not waiting long enough for an answer. Waiting only a few seconds

longer will increase the likelihood of a student answering and will result

in better answers.

▪ Avoid leading questions – questions that imply a particular answer, e.g.,

“Don’t you think that he is more likely to have heart failure, given his

chest findings and gallop rhythm?”

▪ Putting students down for not knowing the answer. When this happens

you lose the students’ respect and they become fearful and learn less.

Even a wrong answer may be partially correct. You can respond in this

way: “You are partly right, but there is another aspect that we need to

consider…”

Q Asking questions helps you to understand how the student is thinking and uncovers their gaps in knowledge or errors in reasoning.

Hypothetical questions are valuable for advanced learners, e.g., “What if the patient were 75 instead of 30, how would that change your differential?”

CLINICAL TEACHING TIPS PAGE 26

AFTER:

TIME FOR REFLECTION:

hile it is important for students to be actively involved in patient

care during the clerkship, it is equally important for them to

have time for reflection and reading in order to consolidate what

they are learning, to relate it to what they have already learned,

and to “make it their own”. Without such reflection, there is the risk that

they simply learn “recipes” for care without a deeper understanding of the

rationale for the approach and without knowledge of the evidence supporting

it. Tell students that you expect them to read around the cases they see.

Periodically ask them to review a topic and provide a summary the next day.

In addition, they need time to reflect on their emotional responses to their

experiences with patients. Clerkship is a time when they may first encounter

death and the terrible unrelenting suffering that some patients endure and

they need time to come to terms with the intense feelings these experiences

may stimulate. Otherwise, in self-defense, they may close off their

emotional reactions. It is important to be sensitive to student’s reactions to

patients, especially dying patients and “difficult” patients. Being open about

your own reactions may make it easier for students to discuss their feelings.

Becoming a physician is a profound life-changing process that can be

challenging and frightening for some students. There are several excellent

books by physician authors, describing their experiences in medical school

or residency, that provide valuable insights about the experience of

becoming a physician and the personal struggles this entails.15,16

OTHER TEACHING OPPORTUNITIES:

any days there will be a few minutes to discuss topics of interest,

e.g., over lunch, while driving to the hospital, office or on a

house. Some preceptors like to spend 15 – 20 minutes at the end

of the day reviewing the most challenging cases or picking up

on one key topic that came up during the day. You could ask, “Who was the

most interesting patient this afternoon?” or “Did anything surprise you

15 One of the best recent examples, in this genre, is Ofri D: Singular Intimacies – Becoming

a Doctor at Bellevue. Boston: Beacon Press, 2003. 16 A good anthology is: Kaminsky L (editor): Writer MD – the Best Contemporary Fiction

and Nonfiction by Doctors. New York: Vintage Books, 2012.

W

M

Learning from experience requires time for reflection. Make sure your students have time to think and wonder.

HERE is a powerful and inspiring TED talk by Abraham Verghese, an American infectious diseases specialist commenting on the importance of the Doctor’s Touch. It will make you reflect on your role as a physician.

CLINICAL TEACHING TIPS PAGE 27

today?” or “How is your experience different from what you expected?”

You might end the day discussing learning objectives with the student. Ask

them what they would like to learn about that evening – they need to be

specific and realistic and should outline what resources they will use

(journal articles, course notes, texts, Internet). But make sure they also have

some time off for recreation each week.

ASSESSMENT AND GRADING:

ll learners are understandably very interested in how they will be

assessed. Each Department has its own method of assessing

students and residents with a variety of tools such as: performance

check lists, multiple choice exams, oral exams, observed physical

exams, projects, etc. Consult the Clerkship or Residency Handbook or your

department coordinator for details about the assessment process in your

discipline. Each department is also interested in identifying outstanding

students for awards. If you think your student deserves an award, please

notify your department Academic Director or Undergraduate Coordinator

and/or add a note to the performance checklist.

WHAT TO DO IF YOUR STUDENT OR RESIDENT

IS NOT DOING WELL:

ur first responsibility is to discuss our concerns with the student or

resident to determine if they have insight into their problem and to

try to figure out the nature of the problem. Tell the student: “I am

concerned that you are not doing well and that you might fail this

rotation if your performance does not improve.” It is natural for us to feel

uncomfortable discussing such concerns and we tend to put it off hoping the

student is “just having a bad day” or similar excuse to avoid confronting

them. The sooner you talk to the student the better. Don’t avoid the “f” word

with vague comments such as: “You aren’t doing as well as I hoped” or

“You need to work harder”. These comments do not convey the seriousness

of the problem.

It may be helpful to ask your colleagues, who have been teaching the

student, for their opinions. Does the student have poor study habits; are they

overwhelmed by the vastness and uncertainties of clinical medicine; do they

have problems with unprofessional behaviour; do they have a physical or

mental illness; do they have personal problems? They may need to be

referred to a faculty member with special skills in working with students in

difficulty. Finally, provide clear and specific advice to the student about

what they need to do to improve.

A

O If the student is not meeting expectations, tell them clearly and directly. Do not “sugar coat” the bad news because they might not recognize the seriousness of their learning needs. Then provide additional help for them to correct their deficiencies.

CLINICAL TEACHING TIPS PAGE 28

This should to be tailored to their particular learning needs. E.g., if their

problem is poor clinical reasoning, they need to read up on the cases they are

seeing by reading about two or three common related problems. If they saw

a patient with shortness of breath, they should read about congestive heart

failure, COPD and asthma and focus on the similarities and differences in

the presentations of each so that they will be able to assess patients with

shortness of breath more effectively. If their problem is poor interviewing

skills, it would be helpful to observe several short segments of their

interviews and provide specific feedback on how they could improve. Role-

playing with you being a patient is another helpful strategy. If their problem

is related to professional behaviour, e.g., frequent lateness or arrogant

behaviour with allied staff, we tend to become more uncomfortable. But the

principles are the same. You need to discuss your concerns as soon as you

notice the problem. Ask the student how they think they can remedy the

problem and follow up in a few days.

s soon as you recognize a student who is not doing well, consult

your department Academic Director (AD) or Undergraduate

Coordinator for advice. They will contact the appropriate people in

the Dean’s office. The Dean’s Office needs to know about students

who are struggling in order to provide additional help if needed and to

address the student’s problems in the context of the whole clerkship. It is

important to provide clear and direct feedback to students about their

deficiencies as soon as possible to give them a fair chance to correct the

problems before the end of that rotation. If they still do not meet the

objectives of the rotation, then they have failed the rotation. The student

needs to be told immediately that they have failed so that there is no room

for misunderstanding. The Clerkship Committee will need enough

information from you about the student so that they can make a decision

about whether or not to grant remediation. It is very helpful to provide

detailed information about the failing student in writing with examples.

Remediation is normally completed early in the final year of medical school

and must be passed. If a student is not granted remediation, or fails

remediation, then they will be asked to leave the medical program. They

have a right to appeal each of these decisions.

REFLECTION ON YOUR TEACHING:

t the end of the day, think about your teaching for a few minutes

and identify a teaching interaction that was effective or ineffective.

Then ask yourself two questions:

1. “Why was this approach effective or ineffective?” and

A

A

Don’t try to “go it alone” with a faltering or failing student. As soon as you recognize a problem, contact your Department Coordinator to discuss your concerns.

The University of Calgary provides this useful outline showing how to approach a learner in difficulty HERE.

CLINICAL TEACHING TIPS PAGE 29

2. “What, if anything, would you (the preceptor) do differently next

time and why?”17

When you try out new teaching methods it may feel awkward at first and

you will be tempted to stick with what you are used to. But, if you stick with

a new skill for about 21 days, the new approach becomes more comfortable

and maybe even second nature. It’s best to try out one new thing at a time

until you make it your own and then add another new technique.

THE TRIPLE C CURRICULUM:

fter an extensive review of postgraduate education in family

medicine, the College of Family Physicians of Canada has

decided that all residency programs in family medicine in

Canada will change to a Triple C curriculum:

1. All residents will be required to achieve competencies to

provide comprehensive care in any community;

2. Their education will provide opportunities to experience

continuity of patient care and continuity with a small number

of family physician teachers;

3. The curriculum will be centred in family medicine – the

primary teachers are family physicians and specialty rotations

will be used only when they can provide essential learning

experiences not available in a family practice setting.

In addition, the curriculum will be competency-based – instead of simply

putting in a prescribed block of time in a series of rotations, learning a “little

bit” about each specialty, every resident will be expected to demonstrate

competence in all of the CanMEDS-FM competencies. The CanMEDS-FM

framework includes competencies to perform seven physician roles: expert,

communicator, collaborator, manager, advocate, scholar and professional. It

is not enough to be a biomedical expert; family medicine graduates must

demonstrate competence in all seven roles.

Additional information about these changes is available on the CFPC

website HERE.

17 Ferenchick G, Simpson D, Blackman J, DaRosa DA, Dunnington GL: Strategies for

efficient and effective teaching in the ambulatory care setting. Academic Medicine.

1997;72:277-280.

A

CLINICAL TEACHING TIPS PAGE 30

OTHER RESOURCES:

▪ In 2003, the BMJ produced a series of excellent articles on the ABCs of

Learning and Teaching. Click HERE for a copy of the full series.

▪ Individual chapters of this resource are available through PubMed

Central on Anne T.-V.’s Blog.

▪ The following journal articles are also valuable for teachers in a

community setting:

o Heidenreich C, Lye P, Simpson D, Lourich M: The search for

effective and efficient ambulatory teaching methods through

literature. Pediatrics. 2000;105:231-237.

o Epstein RM, Cole DR, Gawinski BA, Piotrowski-Lee S, Ruddy

NB: How students learn from community-based preceptors.

Archives of Family Medicine. 1998;7:149-154.

o Goertzen J, Stewart M, Weston W: Effective teaching behaviours

of rural family medicine preceptors. Canadian Medical

Association Medical Journal. 1995;153:161-168.

o Iedema R, Brownhill S, Haines M, et al: ‘Hands on, hands off’: a

model of clinical supervision that recognizes trainees’ need for

support and independence. Australian Health Review.

2010;343:286-291.

o Byrnes PD, Crawford M, Wong B: Are they safe in there? Patient

safety and trainees in the practice. Australian Family Physician.

2012;41(1/2):26-29.

o Miller L, Halpern H: Speed supervision. The Clinical Teacher.

2012;9:14-17.

o Vinson DC, Paden C, Devera-Sales A: impact of medical student

teaching on family physicians’ use of time. The Journal of

Family Practice. 1996;42:243-249.

o Kurth RJ, Irigoyen M, Schmidt HJ: A model to structure student

learning in ambulatory care settings. Academic Medicine.

1997;72:601-606.

here are several excellent journals of medical education and many of

them are available full text online through your medical school

Library. Some of the journals include:

▪ Academic Medicine

▪ Advances in Health Sciences Education: Theory and Practice

▪ BMC Medical Education

▪ Clinical Teacher

▪ Evaluation and the Health Professions

▪ Family Medicine (the official journal of the Society of Teachers of

Family Medicine)

▪ Journal of Continuing Education in the Health Professions

▪ Medical Education

▪ Medical Education Online

T

CLINICAL TEACHING TIPS PAGE 31

▪ Medical Teacher

▪ Teaching and Learning in Medicine

▪ The Faculty Development Office at McGill provides brief descriptions

and links for medical education journals HERE.

WEBSITES FOR MORE INFORMATION ABOUT

TEACHING AND LEARNING:

▪ The College of Family Physicians of Canada has recently created The

Fundamental Teaching Activities in Family MedicineTM: A Framework

for Faculty Development. This is a valuable framework for clinical

teachers that “describes what teachers actually do and helps them

consider creative ways to expand and enhance their teaching activities.”

See FTA.

• The University of British Columbia (UBC) provides several valuable

teaching resources including teaching learners to think, effective

lecturing, teaching skills for community based preceptors, learner-

centred teaching, time-saving tips for clinical teaching, workplace-based

assessment, etc.

▪ “Practical Prof” is an educational resource for rural clinical teachers

developed by the Alberta Rural Physician Action Plan, authored by Dr.

Hugh Hindle with assistance from Dr. Shirley Schipper and Diane Lu. It

is very practical and up-to-date and includes helpful video clips on the

One-Minute Preceptor, SNAPPS, giving feedback, questioning, and the

use of chart stimulated recall. It is the best website on clinical teaching

in primary care that I have seen. Some of the links don’t work, and the

website is due for an updating, but much of it is still working.

▪ London Deanery – Teaching and Learning in Clinical Contexts: A

Resource for Health Professionals. This is a fabulous resource with E-

learning modules on needs assessment, setting learning objectives,

giving feedback, involving patients in teaching and supervision and

much, much more.

▪ The Canadian Family Physician has published a short series of video

demonstrations of common procedures – cryotherapy, toenail resection,

pilar cyst excision, skin tag removal, elliptical excision, punch biopsy,

subungual hematoma, intra-articular knee injections, and shave biopsy,

etc. Go HERE. Each module contains a video and a PDF document.

▪ Teaching Moment consists of a collection of article on several teaching

topics from Canadian Family Physician.

CLINICAL TEACHING TIPS PAGE 32

▪ The Future of Medical Education in Canada (FMEC) is a

comprehensive suite of projects focused on ensuring that Canada’s

medical education system continues to meet the changing needs of

Canadians, both now and into the future. Three extensive reviews of

medical education in Canada – undergraduate education (2010),

postgraduate education (2012) and FMEC MD 2015. These reports

contain detailed analysis of the current state of medical education and

recommendations for change. They also include extensive

environmental scans of different aspects of medical education, e.g.,

generalism, IMGs, distributed education and distance learning,

assessment, professionalism, resident wellness and work/life balance.

▪ A Faculty Development Program for Teachers of International

Medical Graduates – a project of the Association of Faculties of

Medicine of Canada. It contains seven modules - educating for cultural

awareness; orienting teachers and IMGs; faculty development toolbox:

assessing learner needs and designing individually tailored programs;

delivering effective feedback; promoting patient-centred care and

effective communication with patients; untangling the web of clinical

skills assessment. Although targeted to teachers of IMGs, the modules

address generic issues related to clinical teaching for all residents.

▪ University of Miami Miller School of Medicine, Department of Medical

Education, Educational Development Office. This site contains excellent

video recordings of education rounds by leading medical educators.

Click HERE.

▪ The Association of Professors of Gynecology and Obstetrics – Teaching

Tips includes tips on engaging learners, providing feedback, assessing

medical students, role modeling, bedside teaching etc.

▪ Columbia University Pediatrics Clerkship online manual for students

and faculty HERE.

CLINICAL TEACHING TIPS PAGE 33

APPENDIX A LEARNER BACKGROUND FORM

Learner: __________________________ Preceptor: ___________________________

Personal Information (anything that will help the preceptor and practice get to know you better):

Previous Clinical Experience:

Check the rotations you have completed: Medicine Describe your electives/selectives if applicable:

Surgery

OBGYN

Pediatrics

Psychiatry

Family Medicine

Clinical Interests.

Aspects of medicine you have particularly enjoyed or disliked so far and why:

Career interests at this point:

Special requests for this rotation.

Specific topics, skills, problems you hope to address during this rotation (please describe how you hope your

interests might be addressed):

Areas in which you would like specific feedback during the rotation:

CLINICAL TEACHING TIPS PAGE 34

APPENDIX B ORIENTATION CHECKLIST

Orientation to practice:

Learner workspace

Internet access

Library resources

Dress code

Parking, phone system, email

Introduce staff and their individual roles

Unique learning opportunities in this setting

Orientation to community:

Characteristics of the community

Medical resources in the community

Recreational resources

Where to get lunch, buy groceries, do

laundry

Overview of rotation:

Objectives/competencies for the program

Usual schedule – days/hours in the office,

hospital rounds & other scheduled activities

Opportunities for learning skills &

procedures

Others who will be involved in the teaching

On call responsibilities

Amount of reading expected

Arrangements for when primary preceptor is

off or away

Patient care:

Expectation of professionalism – primacy of

the patient, dress code, respect for patients

and staff, honesty, punctuality, patient

confidentiality

Level of responsibility

Length of time to spend with patients

Show a typical exam room and where the

equipment is kept

Charting & EHRs

Dictation

Format for case presentation

Feedback – when, how much, self-

assessment first

Assessment:

Grading policy

Mid-rotation feedback – schedule a time

now ___________________

Show assessment form used

If a problem arises:

How to notify preceptor in an emergency

Importance of contacting preceptor or office

if unexpected absence

Student expectations:

Their personal situation – where they are

from, marital status etc.

Previous experiences in the pre-clerkship

courses and in the clerkship

Goals for the rotation (ask them to write

them down over the first few days) e.g.,

skills they would like to practice, aspects of

medicine they would like to learn more

about

How they learn best

How they feel about the approach outlined

above – anything they would like to modify

to enhance their learning?

CLINICAL TEACHING TIPS PAGE 35

APPENDIX C CLINICAL TEACHING – A LIST OF STRATEGIES

BEFORE:

1. Prepare the Practice or Ward:

Prepare yourself – find out what is

expected

Objective/competencies for the program

Prepare the staff

Prepare the patients

Set up a space for the students

Provide library and Internet resources

2. Create a climate for learning:

Supportive teacher-learner relationship

Authentic responsibility for patient care

Appropriate challenge

3. Orient the student:

See checklist

4. Needs assessment – early and continuing

5. Select appropriate patients and prime the

student before seeing them

DURING:

6. Granting authentic responsibility

Personal qualities

Basic clinical skills

Context and content specific abilities

7. Observe samples of student performance

8. Case presentation:

Provide the student with a framework

for presentations

Have the student make the presentation

in the presence of the patient if

appropriate

9. Use one or more of the 5 microskills:

Get a commitment

Probe for underlying reasoning

Teach general rules

Reinforce what was right

Correct mistakes

10. For a more confident student or resident you

may prefer to use the SNAPPS framework:

Summarize briefly the history and

findings

Narrow the diagnosis or management to

2-3 relevant possibilities – make a

commitment

Analyze the reasoning by reviewing the

findings or examining the evidence

Probe the preceptor by asking questions

about uncertainties

Plan management

Select a case-related issue for self-

directed learning

Some teachers will add Solicit feedback

AFTER:

11. Provide opportunities to practice using

simulation or role-play

12. Provide opportunities for reflection and

reading

13. Discussion

14. Reflect on your teaching

15. Read about teaching – see references

16. If there are problems, ask for help

CLINICAL TEACHING TIPS PAGE 36

Appendix D Tips for Case Presentations

In presenting a case, you need to be prepared to give information about the patient’s current

concerns, other problems, medications, the patient’s illness experience, their ideas and

aspirations about their health, their life context, the physical examination, laboratory

investigations, differential diagnosis and treatment plans. Because time is limited for office visits

in a family practice, it is not realistic to expect students or residents to address all of these issues

in a single visit. The focus should be on the main concerns of both patient and physician and any

other problems that might influence the treatment of the main concern or are serious in their own

right. Knowing something about the patient’s ideas, preferences and their life situation are often

essential for developing a realistic treatment plan acceptable to the patient. Many follow-up visits

for patients with chronic conditions involve the assessment and management of several

problems. Typically, in family medicine, patients present with an average of 3 problems.

Students and residents need to become skilled in collaborating with patients in prioritizing the

problems that require the most attention. Sometimes, other problems and concerns must be

deferred to a follow-up visit.

Because different preceptors have different preferences for how students and residents should

present a patient’s story, the “Signpost Method” is a valuable approach. Start by outlining who

the patient is and summarize what you have already done, e.g., “I just saw Roger Smith for a 3-

day history of low back pain getting so bad today that he could not work. I think it is most likely

a herniated disk. I have completed a history of his present problem, relevant personal and social

history, physical examination and I have a plan for investigation and treatment. What would you

like to hear more about?” Then the preceptor will ask for more information about one or more

aspects of your workup. For more about the Signpost Method, see the video HERE by Dr. David

Keegan in Calgary.

Below is an outline of what might be expected for each area of the workup:

1. Start with a summary of the patient and their concerns: “Mr. Jones is a 75-year-old

retired accountant who presents today concerned about a 3-week history of feeling tired,

a non-productive cough and mild shortness of breath. His active problem list includes:

poorly controlled type II diabetes, BMI 32, depression, gout and osteoarthritis. His

medication list includes: citalopram, allopurinol, metformin and naproxen.”

2. Present the patient’s illness experience: “Mr. Jones initially felt that he had a viral

infection but now is worried that it could be something more serious. He wonders if he

should have an antibiotic and maybe a chest X-ray.”

3. Present the patient’s ideas about his health: “His idea of health is having more energy

and being active with church activities and volunteer work. He hopes to get more

involved again. I note that he has never had the pneumonia vaccine.”

CLINICAL TEACHING TIPS PAGE 37

4. Briefly present who the patient is: “Arnold Jones was manager of a small firm of

accountants for many years and retired 5 years ago when his firm went bankrupt. He was

previously active in volunteer work with his church but since his wife died he has

become quite isolated and inactive. He lives alone in a small apartment. His wife died a

year ago and his 3 children live in the U.S. He rarely sees them.”

5. Present the history and findings: Instead of presenting the HPI (history of present

illness), present the story of each of the active problems starting with the most relevant

one. Present it based on how you have organized your thinking around it and not the

sequence in which you collected the information when you took the history!!!! Time

being short, you may not have time to deal with more than two or three problems. But,

other problems that influence the main problem or that are serious might still need to be

addressed, e.g., in the case of Mr. Jones, the poorly controlled diabetes and depression

might be important in treating a chest infection. Do not present every piece of

information you collected (i.e., you may say things like “the remainder of the ROS was

negative”).

6. Present the results of your physical exam and investigations: It is appropriate here to

also identify any areas of the exam or interpretation that you struggled with and wanted

the preceptor to double check. Acknowledge areas where you got stuck (For example:

“When we go in to see the patient, could you double check the JVP.”)

7. For the main problem, and any related or serious problems threatening the

patient’s life or health, now address:

a. Presumptive diagnosis and differential diagnosis

b. Be prepared to analyze the differential by comparing and contrasting the

possibilities

c. Present your diagnostic and or therapeutic plan commenting on the patient’s

preferences and values

d. Probe your preceptor by asking questions about uncertainties, difficulties, or

alternative approaches. Acknowledge areas where you got stuck (for example:

“When we go in to see the patient, could you double check the JVP.”)

Note: Each preceptor has their own preference for format so be sure to find out what the

expectation is. Some preceptors also prefer that you present the case in front of the patient. Be

sure to pay attention to your use of “medical vs. layman” language in these situations and always

acknowledge the patient as you present.

CLINICAL TEACHING TIPS PAGE 38

PLANNING

• Preparation

• Orientation

• Priming

DX PATIENT & LEARNER & TEACHING

• 5 microskills

• SNAPPS

• Observe

• Model

REFLECTING

• Discussion

• Reflection

• Reading

• Ongoing needs assessment

• Relationship building

• Climate setting

Based on Irby

Clinical Teaching – a Framework

Appendix E Schematic of the Before-During-After Framework

CLINICAL TEACHING TIPS PAGE 39

Appendix F

The One-Minute-Preceptor Model

1. Get a commitment, i.e., ask the student to commit

themselves to a diagnosis or plan for investigation or

management

2. Probe for supporting evidence – ask the student how they

came to their conclusions

3. Teach general rules – what is the “take home” message

from this experience

4. Reinforce what was right

5. Correct mistakes

CLINICAL TEACHING TIPS PAGE 40

Appendix G

The SNAPPSS Model

S – Summarize briefly the history and findings. This should take

no more than 50% of the time of the presentation and

discussion.

N – Narrow the diagnosis or management to 2-3 relevant

possibilities – make a commitment.

A – Analyze the reasoning by reviewing the findings or

examining the evidence – compare and contrast the

possibilities.

P – Probe the preceptor by asking

questions about uncertainties.

P – Plan management.

S – Select a case-related issue for self-

directed learning.

S – Solicit feedback.